Lateral Ankle Instability after Rotational Injury: A Case Report

Abstract

Introduction: One of the most common orthopedic injury injuries seen in patients at the emergency department is that of the ankle. There are some efficient protocols for their treatment, but more often the clinician is fo-cused in finding and treating possible fractures and disregards ligamentous lesions that lead to instabil-ity, if they become chronic.

Case report: A patient that suffered an ankle sprain was improperly handled, developed lateral instability of the ankle, and was treated surgically using an autologous semitendinosus graft. A 42-year year-old Caucasian male that after an ankle sprain was examined in various primary health -care centers, four times within six 6 months, with persistent symptoms of his left ankle. After all these months, he was eventually diagnosed with post-traumatic lateral instability of the ankle that was resistant to con-servative treatment. In stress view X-rays, the talar tilt angle was 21°ο and the anterior drawer was measured at 13 mm. The patient was treated surgically with reconstruction of the anterior talofibular and the calcaneofibular ligament using an autologous semitendinosus graft from the left knee. The graft was pinned in the anatomical insertion sites of the ligaments with absorbable screws. A post-surgical physiotherapy regimen was applied for two 2 months. In the post-surgical dynamic stress view X-rays, the talar tilt angle and the anterior drawer were markedly improved, measured at 3°ο and 4 mm, respec-tively. In 11 months post-surgical follow-up, the patient's American Foot and Ankle Score was 85, from the 60 evaluated before treatment.

Conclusion: The use of guidelines, regular follow-ups, and functional rehabilitation are key factors to treating ankle injuries. The reconstruction of lateral collateral ligament complex with a semitendinosus graft is one of the surgical options for restoring lateral ankle instability.

Keywords: Ankle sprain; autologous semitendinosus graft; lateral instability of the ankle.

Figure 1

Stress radiograph anteroposterior of the left ankle, taken while an assistant performed varus stress forces on the ankle. (left picture).

Figure 2

Stress radiograph profile of the left ankle, taken while an assistant performed posterior stress forces on the ankle.(right picture). The subluxation is apparent in both radiographs.

Figure 3

Marking the incision. The incision is marked over the lateral malleolus.

Figure 4

Harvesting the semitendinosus graft with a small medial oblique incision of the knee. A small oblique incision is made over the pes anserinus. The semitendinosus tendon is identified under the sar-torius tendon, its attachments to the crural fascia dissected, and the graft harvested.

Figure 5

The ankle approach. After careful dissection, the destruction of the lateral ankle ligamentous complex is apparent.

Figure 6

Tunnel preparation in fibula, talus, and calcaneus. The fibular tunnel is prepared.

Figure 7

Tunnel preparation in fibula, talus, and calcaneus. The talar tunnel has been prepared.

Figure 8

The graft has been fixed. The graft can be seen after the insertion of the absorbable screws and its tensioning. The reconstruction is complete.

Figure 9

Anteroposterior (left) and profile (right) stress radiographs of the left ankle after the recon-struction under anesthesia. The radiographs were taken with the same technique and the same assistant as pre-surgical reconstruction. No subluxation is visible in these radiographs.